Provider Demographics
NPI:1538787288
Name:ISAILOVICH, WAYNE M (LAC)
Entity type:Individual
Prefix:
First Name:WAYNE
Middle Name:M
Last Name:ISAILOVICH
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7805 TAFT ST STE E
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-5237
Mailing Address - Country:US
Mailing Address - Phone:219-756-3791
Mailing Address - Fax:
Practice Address - Street 1:7805 TAFT ST STE E
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-5237
Practice Address - Country:US
Practice Address - Phone:219-756-3791
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-09
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty